Health Literacy

Communicating Across a Life Span: Universal Design in Print and Web-based Communication

Article from the Boston Globe’s On Call Magazine, January 2001

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

The 1990 Americans with Disabilities Act prohibits discrimination against disabled individuals, and mandates that public organizations and services provide reasonable accommodations to meet varied physical needs. The concept of universal design” goes beyond what is mandated by the ADA. It is an approach to design that not only addresses specific physical disabilities, but also takes into account a wide array of physical, cognitive, and linguistic abilities of people throughout the world over an entire life span.

“Universal design,” says Valerie Fletcher, executive director of Adaptive Environments in Boston, “assumes human ability is endlessly varied and changes over time.” An example of universal design is curb cuts. Required by law, curb cuts not only accommodate people who use wheelchairs, they also benefit children on scooters, adults pushing baby carriages and wheeled suitcases, and seniors using walkers.

According to the Center for Universal Design at North Carolina State University, “Universal design is the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design. The intent…is to simplify life for everyone by making products, communications, and the built environment more usable by as many people as possible at little or no extra cost.”

Universal Design and the Creation of Clear Messages

Universal design is an important concept in effective communication. Signage, for example, addresses people’s diverse abilities when it includes easy-to-recognize graphics, large print, raised or Braille lettering, and color combinations that people can see. “If a design works well for a person with a disability,” says Fletcher, “it probably works better for everybody.”

Graphic designers often collaborate with disability experts, creating designs that are both functional and aesthetically appealing. Hans van Dijk, a professor in the graphic design department at the Rhode Island School of Design in Providence, Rhode Island, works with Fletcher to create designs that meet the needs of people of all ages and abilities. Here are some of their suggestions about ways health care providers can use universal design principles in print and Web-based communications.

Assemble a team. Identify the team that will be involved in the design of your communication. Work with that team right from the start to incorporate concepts of universal design into the message presentation. If you are  creating written patient education materials, for example, your team might include clinical and administrative staff, graphic designers, marketing professionals, and “user/experts,” who are patients or family members.

Include user/experts. User/experts represent the consumers you are designing for. Solicit their opinion as you design materials, asking them about both usability and appeal. Fletcher finds that user/experts are generally pleased to help. That’s because they know their opinion will make a difference.

Start by using the smallest group possible, suggests van Dijk. Get your first- questions answered by one or two user/experts, and then extrapolate this information to a larger population. Elicit feedback for the communication product you are designing by asking open-ended questions such as, “How would this work best for you?” Also explore with the group the effectiveness of more specific elements such as color combination.

Balance opposing needs. Sometimes one person’s needs and preferences are directly the opposite of someone else’s. For example, a person with low vision may prefer reverse lettering – light print on a dark background – while a person with normal vision may prefer dark lettering on a light background. Find ways to make accommodations for both preferences in critical elements of your design. For example, you might use reverse lettering in key parts of a brochure, such as the title and headings, while using standard lettering in the body of the text. The reverse lettering will make it easier for everyone to find key information.

Focus on These Elements of Design

Here are some concepts of universal design to keep in mind when creating printed materials for your patients or materials they will access on the Web. Doing so will help create effective communications for the largest number of people.

Font. Choose a font that is not overly stylized and does not vary too much from what people are used to seeing. People often have strong opinions about font. Some prefer serif fonts. These are fonts in which the letters have little “feet” or “wings.” An example might be Times New Roman, which is a common font in most word processing programs. Others favor sans serif fonts. These are fonts that use block letters, such as the ones on this page.

While there is no clear-cut choice for which is best for printed materials, van Dijk says, sans serif fonts work better for Web-based and Power Point presentations. In fact, there are new fonts that are being designed specifically for use on the Web because they seem easier to read. One of these is Verdana from M/S Word.

Type size. For regular text, use a type size between 12 and 16 points. Type that is smaller than 12-point can be hard for people to see. Type that is larger than 16-point can result in creating too many pages to be read comfortably.

Line length. People with low vision may have difficulty when there are too many words on a line, and people with cognitive impairments may have difficulty when there are too few words per line. In general, most people find it comfortable to read 7 to 12 words in a line of continuous, or running, text. Newspaper-type columns can work well, as long as they are sufficiently wide enough to accommodate large-sized print. In addition to being aware of the number of words on a line, you should make sure you justify (line up evenly) the text on the left margin, and keep the right margin ragged (uneven). Doing so makes it easier for your reader to move through the page.

Pictures. Choose pictures that have sufficient contrast between foreground and background. Crop the pictures so that they have a clear border around a central image. When you include pictures on your Web site, provide descriptive text alongside graphic images. Some people find it easier to get information from text than from pictures.

Paper finish. Glossy paper has a glare that can be difficult to see by people with impaired vision. To increase legibility, use matte paper for all your printed materials.

Slide Design. To ensure that overhead slide presentations, such as those created with Power Point, are easy-to-see and easy-to-understand, use a sans serif font as you would for presenting text on the Web. And have no more than 5 lines of text on each slide with no more than 5 words on each line. That way, your audience will find it easier to take in the information you are presenting.

To Learn More

Adaptive Environments is a Boston based non-profit educational organization dedicated to promoting accessibility and universal design. The public is welcome to visit their extensive library of materials about disability and design. For information, contact Valerie Fletcher, executive director of Adaptive Environments by phone at (617) 695-1225, extension 26, or by e-mail at You can also visit their Web site at:

The Rhode Island School of Design (RISD) offers instruction in universal design. RISD’s students and faculty are sometimes available to help healthcare organizations design materials that are accessible to all. For information, contact Professor Hans van Dijk at the Graphic Design department by e-mail at

Cast is a not-for-profit organization that offers “Bobby,” a free Web-based service to help Web page authors identify and repair significant barriers to access by individuals with disabilities. To learn more, visit the Web site at:

The Trace Center is a leading resource on universal design. It is currently working on ways to make standard information technologies and telecommunications systems more accessible and usable by people with disabilities. To learn more, visit their Web site at

Article reprinted with permission from On Call magazine and published by a division of Boston Globe Media.